History Particulars
Name: Mr. K.C.
Age: 18 yrs Sex: Male
Religion: Hindu
Education: +2
Occupation: Student
Address:
• Permanent: Sinamangal
Date of admission: 20th Kartik 2063
Mode of admission: OPD
Date of examination: 22nd Kartik 2063
Chief Complaints
• Discharge in right ear - 2 years
• Hearing loss in right ear - 2 years
History of Present Illness
According to the patient he was apparently well 2 years back. Then he had discharge in right ear which was gradual in onset, pale yellow in color with no blood stain, profuse in amount with foul smell, aggravated during attacks of common cold with no relieving factor and was associated with impairment of hearing of the right ear.
Impairment of hearing was gradual in onset in the diseased ear since last two years and no other associated symptoms.
There is no history of pain, vertigo, fever and headache.
Past History
• There is no history of similar symptoms before.
• No history of any ear surgery the past.
• No history of Tuberculosis, Diabetes Mellitus and Hypertension.
Personal History
• Bowel: Normal
• Appetite: Normal
• Stool: Normal
• Urine: Normal
• He is a non smoker, does not consumes alcohol and is a non-vegetarian
Family History
• No history of ear diseases like Otosclerosis, Hearing loss in the family members
• No history of Tuberculosis, Diabetes Mellitus and Hypertension in the family
Socioeconomic History
He is a student, there are four members in the family, joint family with good housing condition and safe drinking water, toilet facility is present and the family falls in the middle class group.
Drug & Allergy History
No known history of allergy to drugs, dust and food and not taking any medication.
Clinical Examination A. General Examination 1. General Characteristics
- Appearance : Well looking
- Body built : Well built
- Conciousness :Conscious
- Decubitus : Sitting
- Cooperative
- Well oriented to time, place and person
- Nutritional status is good
Pallor : Not present
Icterus : Not present
Lymphadenopathy : Not present
Leuconychia : Not present
Clubbing : Not present
Cyanosis : Not present
Oedema : Not present
Dehydration : Well hydrated
2. Vitals Pulse: 75/minute, regular in rhythm, normal in volume and character, no radio-radial and radio-femoral delay, condition of arterial wall is normal and all peripheral pulses are palpable.
Blood pressure: 120/80 mm of Hg in the right arm in sitting position.
Respiration: 18/minute in sitting position, normal in depth and thoraco-abdominal in nature.
Temperature: 97ºF
JVP: Not raised.
B.
Local Examination Ear Examination A. Examination without speculum
1. Pinna
• Both pinna are normal in shape and size
• Normal in position
• No visible swelling and scar marks
2. Post aural region
• No visible swelling in both ear
• No sinus and fistula in both ear
• No scar marks in both ear
• No mastoid tenderness in both ear
3. Tragus
• No tenderness in both ear
4. Preauricular region
• No scar mark
• No sinus and fistula
5. External Auditory Canal
• No visible swelling, redness or impact wax in both external auditory canal.
B. Examination with speculum 1. External Auditory Canal
• No impacted wax, visible swelling, redness and pain in both the ears.
Tympanic Membrane
Cone of light
• Present in the left ear
• Absent in the right ear
Color of Tympanic Membrane
• Left tympanic membrane is normal pink in colour.
• Right tympanic membrane looks congested
3. Position
• Left tympanic membrane is in normal position
• Right tympanic membrane is slightly retracted in the posterior superior quadrant.
4. No vesicles in both right and left tympanic membrane
5. Perforation
• There is no perforation of the left tympanic membrane
• Single central perforation of the right tympanic membrane involving mostly the anterior inferior and posterior inferior quadrant and is of kidney shaped.
6. Mobility of TM
• Normal mobility of left tympanic membrane.
C. Hearing Test: (Tuning Fork Test)
(Detail is vailable in the book)
Nose Examination
No abnormal findings.
Oral Cavity Examination
No abnormal findings.
Neck Examination
There is no any visible swelling in the neck.
B. Systemic Examination Respiratory System: Bilateral vesicular sound heard, no added sound
Cardiovascular system: First and second heart sound heard, no murmur.
Per Abdomen Examination: Soft, non tender and no organomegaly
Central Nervous system: Intact
Provisional Diagnosis
Chronic Suppurative Otitis Media
Differential Diagnosis
• Foreign body
• cholesteatoma
• Wegener Granulomatosis
Investigation
• Examination under microscope
• Pure tone audiometry
• Culture and sensitivity of the ear discharge
• X-ray mastoid
Final Diagnosis Management
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